The MACs officially resumed post-payment medical review of items and services with dates of service prior to March 2020 this past August, but according to a June 3, 2021 announcement may now officially begin conducting post-payment medical reviews for later dates of service. The Targeted Probe and Educate program will restart later per MLN Connects of June 3, 2021.  Last week’s blog reviewed considerations for effective ADR response in preparation for an uptick in medical review activity. This week, let’s review some of the top risk areas that are ripe for scrutiny under PDPM claim reviews.

Top 5 Risk Areas for PDPM Medical Review

  1. The Function Score (Section GG) impacts your PDPM rate in the nursing component and the OT/PT component. The usual performance coded in Section GG must be consistent with the clinical assessment documentation in the resident’s medical record. Be sure your medical review response team knows where to locate the supporting documentation. Reviewers are focusing on usual performance accuracy as well as documentation to support the IDT collaboration. In medical review, discrepancies identified between the MDS coding and supporting documentation will contribute to your medical review error rate and potentially result in financial recoupment.
  2. Active Conditions in Section I must include Physician-Signed Diagnosis, and must be considered active within the 7-day lookback period. No one but physicians and physician extenders can diagnose; providers cannot infer a specific diagnosis because the documentation appears to support the specific condition or ICD.10-CM code. The physician endorsed diagnosis is often the critical piece missing from the medical record. Providers should review (or develop) physician query processes to ensure the diagnosis is accurate, active and coded at the most specific level for the patient identified in the lookback period. If applicable, your medical review response team should know how to generate physician order reports with the appropriate electronic signatures.
  3. Nursing daily skilled service documentation is more important than ever to justify the nursing case mix component of PDPM. Gone are the days of reviewing rehab documentation and ADL coding alone to support the SNF stay. High risk areas under medical review include care plans, justification of daily skill and specifically treatments and services that support all conditions coded as active on the MDS.
  4. Ensure pertinent hospital documentation is included in the ADR packet. Key records may include, but are not limited to, the hospital admission H&P and relevant progress notes, discharge summary, diagnostic reports, hospital medication and treatment records, as well as operative notes, consult reports and other documentation related to care, services, history and surgical procedures. Each of these may include relevant services and conditions impacting the need for SNF service delivery and determination of the accurate PDPM payment rate.
  5. Coding Isolation has significantly increased across providers as a result of the COVID-19 pandemic. However, the RAI requirements have not changed. Isolation may not be coded on the MDS if it is only in place to prevent contracting the COVID 19 virus as precautionary isolation does not meet RAI criteria. Similarly, isolation criteria are not met when cohorting patients together in a shared room with a similar active infection. Isolation may only be reported when the resident has an active infection and meets conditions for single room isolation as outlined per RAI, pg. 0-5.

In addition to this priority list, providers should consider defensive documentation related to application of SNF waivers during the Public Health Emergency, as well as any significant changes in case mix distributions since the onset of PDPM. Consider how well the Facility Assessment supports changes in patient acuity. QAPI activities should include monitoring that promotes MDS timeliness, accuracy and validity, as well as review of the level to which documentation and care planning clearly support coding and individual services.

In short, the accuracy of coding, documentation and data monitoring is vital as we prepare for PDPM medical review audit activity.   For more information on CMS guidance for Medicare Administrator Contractors (MACs) on Medical Review Instructions related to Skilled Nursing Facilities, see Publication 100-08 Medicare Program Integrity, Transmittal 924.

Will your coding and documentation withstand Medical Review Scrutiny? Contact Proactive for assistance in ensuring readiness for complex Medical Review by scheduling a remote PDPM compliance audit.


Blog by Amie Martin OTR/L, CHC, RAC-CT, MJ, Proactive Medical Review

Learn more about Amie and the rest of the Proactive team.